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L.C.H.

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L.C.H. last won the day on October 12 2019

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    AP/CP general pathologist, BB medical director

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  1. Also low in southern new england; we were unable to make a full Rh-neg MTP pack this week for an Oneg postpartum bleed.... fortunately they didnt use all the reds and the Rh-pos came back to us. eesh!
  2. Malcolm, thank you for the article! I hope to get to it today. It appears cff DNA testing is available in the US for some things (DiGeorge, for instance), but I am not readily finding a lab that offers RHCE testing. Am going to keep looking. I guess my main concern is that since anti-c can kick up later in pregnancy, if we see an early anti-E in mom, should we advise to 1) test dad (or fetus with cff if i can find it) for not just E but also c antigen and/or 2) request an additional screen later in the pregnancy to see if anti-c has come up? (presuming mom is c-negative)
  3. ahh, i've been at a specialty hospital for too long, i forgot FOB is also fetal occult blood. :-)
  4. oops, John C. Staley - sorry for the abbreviations! MFM = maternal-fetal medicine; FOB = father of baby
  5. Hello, all - We've been having some back and forth with our MFM department and their handling of maternal antibodies. When the mom has an antibody, they test dad for the antigen, and then stop following if negative, and are resisting any change to this (see below for why i find this a problem). I pulled the ACOG Practice Bulletin 192, March 2018 and indeed that is the standard of care per ACOG (although there was NO reference for that entire section of the paper, so i dont know where that info came from). However, we had a case (with MFM) earlier this year where mom had an anti-E on her initial T+S, and they tested dad, dad was negative, so they stopped following.... Then six months later just before delivery we find an anti-c with a roaring titer, with a problematic outcome. So I am kinda not OK with just testing dad and letting it all go when it comes to Rh antigens. Any words of wisdom here? I am going to be tangling with MFM over policy in the new year, and this is certainly on the docket. thank you -
  6. Pathologist here. I realize this inquiry is kinda old now, and i am sorta curious to find out the resolution of this issue from the OP. I can see if the tech wanted to send a photo as a 'curbside' to see if it is a skiptocyte that maybe this would be OK, and up to the individual tech if they choose to use their phone for that. However, I find it a little weird (and bad practice) that the pathologist who is director is not around/onsite at least once a day to look at slides. If it's for a real review, then no, too bad. There are those numbered hashmarks on all scope stages so you can send along the coordinates of the area of concern. Alternatively, and it depends on the scope model you use, but one place I worked you could flip the condenser down and dot the cell on the underside of the slide. Takes the right scope and some practice, but is doable.
  7. we have a 70 bed NICU in new england; we have about 3 neonatal exchanges each year. however, we've have had two in the past month; one for maternal:fetal ABO incompatibility (due to B, strangely), and one for anti-D HDN (no hydrops) that they tried to manage first with IVIG but after a couple weeks moved on to an exchange.
  8. Malcom Needs, thank you, I will check it out!
  9. i ended up finding a reference that actually provided the half-life of rhogam, which is the product we use, and the minimum blood concentration needed to prevent immunization. it's the math behind the 28 week dose covering up to 40 weeks comes from, i dont know why neither I nor my BB manager learned this during our training! i also pinged a senior OB I trust about this stuff, and he said she's very likely covered by what she's already got, but can redose if so desired. So since we gave her 300 mcgs a week ago, we advised that she is very likely completely covered (she should still have almost the full dose in her system just one week out), but that OB can dose again if she feels squirrely about it. D. Salkin, thanks for your input! sounds about like what i ended up with.
  10. quick addendum - evidently we do not give microdoses, so she got a full dose for the amnio, which should cover the D&C!
  11. I have a question from a clinician that I cant seem to answer despite checking ACOG guidelines: Pt is Rh negative. Had amniocentesis five days ago, for which she received rhogam. Now she is scheduled for a D&C tomorrow (16 wks GA) and OB wants to know if more anti-D is indicated. I heard a rumor that there is an ACOG recommendation for these situations, but cant find it. My gut feeling is that to be safe, additional anti-D should be given, b/c the dose given for amniocentesis might not be large enough to cover for the D&C (ignoring the whole timing thing). Does anyone have any wisdom about this?
  12. thank you Malcom and Scott for you responses! We spoke with the clinicians, who seem to understand the anti-S titer number will not tell them much of anything, and they had already realized the Jk and the C were useless to titer (which saved us a lot of grief). They could not provide any references or good reasons for needing the anti-S now, but pretty much insisted, and we acquiesced on this patient ONLY since her situation is quite unique. So we are treating the clinician rather than the patient this time; I've been covering clin path long enough to know that sometimes this is just the way it goes. Anyhow, we have at least opened a line of communication to the clinicians in the case and they feel we are trying to help them (even if we think it's silly), and that may be all the reassurance they need. And was better to know about this patient sooner rather than later, b/c if she does make it all the way to delivery with a chronic anemia we were gonna need to plan for her anyway. At least she's now on our radar in BB. Again, thank you all for your expert opinions! LCH
  13. We have a woman with a complicated history who is trying to conceive. She has h/o many transfusions and is followed by heme (for anemia) and repro endocrinology. She is B pos with anti-C, anti-Jka, anti-S. The prospective father has been genotyped for the corresponding antigens and is c/c, Jkb/Jkb, and S/s. The clinicians want us to titer her antibodies now, before she has conceived. This isn't something we typically do; our docs usually start titers at the first prenatal visit. We havent been able to get a good reasoning out of the clinicians about why this makes sense to do in this particular patient (and I am leery of letting a bad habit get started), although I do admit she is very complicated. I will be pushing back on the Jka and the C, since dad is antigen-negative. But I may have to give in on titering the anti-S, since he does carry it, and I cant point to any reference that gives a good reason not to. Any thoughts/info/experience?
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